White Rock Medical Center

All Charges

Charge

Type

Setting

Price

SLP Fiberoptic Swallow Eval Units

Facility

$603.00

Service Code	CPT 92612 GN
Hospital Charge Code	5902612
Hospital Revenue Code	444
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$391.95
Rate for Payer: Aetna Commercial	$331.65
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$121.66
Rate for Payer: BCBS of TX Blue Essentials	$145.43
Rate for Payer: BCBS of TX PPO	$162.21
Rate for Payer: Cash Price	$530.64
Rate for Payer: Cash Price	$530.64
Rate for Payer: Cash Price	$530.64
Rate for Payer: Cash Price	$530.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$391.95
Rate for Payer: Multiplan Commercial	$391.95
Rate for Payer: Multiplan Workers Comp	$391.95
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$82.01

SLP Fiberoptic Swallow Eval Units BCE

Facility

$603.00

Service Code	CPT 92612 GN
Hospital Charge Code	5902612
Hospital Revenue Code	444
Rate for Payer: Cash Price	$530.64

SLP Fiberoptic Swallow Eval Units BCE

Facility

$603.00

Service Code	CPT 92612 GN
Hospital Charge Code	5902612
Hospital Revenue Code	444
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$391.95
Rate for Payer: Aetna Commercial	$331.65
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$121.66
Rate for Payer: BCBS of TX Blue Essentials	$145.43
Rate for Payer: BCBS of TX PPO	$162.21
Rate for Payer: Cash Price	$530.64
Rate for Payer: Cash Price	$530.64
Rate for Payer: Cash Price	$530.64
Rate for Payer: Cash Price	$530.64
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$391.95
Rate for Payer: Multiplan Commercial	$391.95
Rate for Payer: Multiplan Workers Comp	$391.95
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$82.01

SLP Flexible Endoscopic Evaluation Units

Facility

$711.00

Service Code	CPT 92616 GN
Hospital Charge Code	5902616
Hospital Revenue Code	444
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$462.15
Rate for Payer: Aetna Commercial	$391.05
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$178.09
Rate for Payer: BCBS of TX Blue Essentials	$212.89
Rate for Payer: BCBS of TX PPO	$237.45
Rate for Payer: Cash Price	$625.68
Rate for Payer: Cash Price	$625.68
Rate for Payer: Cash Price	$625.68
Rate for Payer: Cash Price	$625.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$462.15
Rate for Payer: Multiplan Commercial	$462.15
Rate for Payer: Multiplan Workers Comp	$462.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$96.70

SLP Flexible Endoscopic Evaluation Units BCE

Facility

$711.00

Service Code	CPT 92616 GN
Hospital Charge Code	5902616
Hospital Revenue Code	444
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$462.15
Rate for Payer: Aetna Commercial	$391.05
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$178.09
Rate for Payer: BCBS of TX Blue Essentials	$212.89
Rate for Payer: BCBS of TX PPO	$237.45
Rate for Payer: Cash Price	$625.68
Rate for Payer: Cash Price	$625.68
Rate for Payer: Cash Price	$625.68
Rate for Payer: Cash Price	$625.68
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$462.15
Rate for Payer: Multiplan Commercial	$462.15
Rate for Payer: Multiplan Workers Comp	$462.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$96.70

SLP Flexible Endoscopic Evaluation Units BCE

Facility

$711.00

Service Code	CPT 92616 GN
Hospital Charge Code	5902616
Hospital Revenue Code	444
Rate for Payer: Cash Price	$625.68

SLP Flexible Fiberoptic Endoscopic Eval Units

Facility

$646.00

Service Code	CPT 92614 GN
Hospital Charge Code	5902614
Hospital Revenue Code	444
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$419.90
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$119.14
Rate for Payer: BCBS of TX Blue Essentials	$142.42
Rate for Payer: BCBS of TX PPO	$158.85
Rate for Payer: Cash Price	$568.48
Rate for Payer: Cash Price	$568.48
Rate for Payer: Cash Price	$568.48
Rate for Payer: Cash Price	$568.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$419.90
Rate for Payer: Multiplan Commercial	$419.90
Rate for Payer: Multiplan Workers Comp	$419.90
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$87.86

SLP Flexible Fiberoptic Endoscopic Eval Units BCE

Facility

$646.00

Service Code	CPT 92614 GN
Hospital Charge Code	5902614
Hospital Revenue Code	444
Min. Negotiated Rate	$80.00
Max. Negotiated Rate	$419.90
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$119.14
Rate for Payer: BCBS of TX Blue Essentials	$142.42
Rate for Payer: BCBS of TX PPO	$158.85
Rate for Payer: Cash Price	$568.48
Rate for Payer: Cash Price	$568.48
Rate for Payer: Cash Price	$568.48
Rate for Payer: Cash Price	$568.48
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$419.90
Rate for Payer: Multiplan Commercial	$419.90
Rate for Payer: Multiplan Workers Comp	$419.90
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$87.86

SLP Flexible Fiberoptic Endoscopic Eval Units BCE

Facility

$646.00

Service Code	CPT 92614 GN
Hospital Charge Code	5902614
Hospital Revenue Code	444
Rate for Payer: Cash Price	$568.48

SLP Fluoroscopic Evaluation Units

Facility

$506.00

Service Code	CPT 92611 GN
Hospital Charge Code	4405627
Hospital Revenue Code	444
Min. Negotiated Rate	$68.82
Max. Negotiated Rate	$328.90
Rate for Payer: Aetna Commercial	$278.30
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$159.91
Rate for Payer: BCBS of TX Blue Essentials	$191.15
Rate for Payer: BCBS of TX PPO	$213.21
Rate for Payer: Cash Price	$445.28
Rate for Payer: Cash Price	$445.28
Rate for Payer: Cash Price	$445.28
Rate for Payer: Cash Price	$445.28
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$328.90
Rate for Payer: Multiplan Commercial	$328.90
Rate for Payer: Multiplan Workers Comp	$328.90
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$68.82

SLP Fluoroscopic Evaluation Units BCE

Facility

$506.00

Service Code	CPT 92611 GN
Hospital Charge Code	4405627
Hospital Revenue Code	444
Min. Negotiated Rate	$68.82
Max. Negotiated Rate	$328.90
Rate for Payer: Aetna Commercial	$278.30
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$159.91
Rate for Payer: BCBS of TX Blue Essentials	$191.15
Rate for Payer: BCBS of TX PPO	$213.21
Rate for Payer: Cash Price	$445.28
Rate for Payer: Cash Price	$445.28
Rate for Payer: Cash Price	$445.28
Rate for Payer: Cash Price	$445.28
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$328.90
Rate for Payer: Multiplan Commercial	$328.90
Rate for Payer: Multiplan Workers Comp	$328.90
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$68.82

SLP Fluoroscopic Evaluation Units BCE

Facility

$506.00

Service Code	CPT 92611 GN
Hospital Charge Code	4405627
Hospital Revenue Code	444
Rate for Payer: Cash Price	$445.28

SLP Neurobehavioral Status Examination Units

Facility

$527.00

Service Code	CPT 96116 GN
Hospital Charge Code	5900830
Hospital Revenue Code	918
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$650.28
Rate for Payer: Aetna Commercial	$289.85
Rate for Payer: Aetna Medicare	$430.59
Rate for Payer: Amerigroup CHIP/Medicaid	$47.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$287.06
Rate for Payer: Amerigroup Medicare	$287.06
Rate for Payer: BCBS of TX Blue Advantage	$158.10
Rate for Payer: BCBS of TX Blue Essentials	$189.72
Rate for Payer: BCBS of TX Medicare	$287.06
Rate for Payer: BCBS of TX PPO	$210.80
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cigna Commercial	$650.28
Rate for Payer: Cigna Medicare	$287.06
Rate for Payer: Employer Direct Commercial	$287.06
Rate for Payer: Humana Medicare/TRICARE	$287.06
Rate for Payer: Molina Dual Medicare/Medicaid	$287.06
Rate for Payer: Molina Medicare	$287.06
Rate for Payer: Multiplan Auto	$342.55
Rate for Payer: Multiplan Commercial	$342.55
Rate for Payer: Multiplan Workers Comp	$342.55
Rate for Payer: Scott and White EPO/PPO	$5.13
Rate for Payer: Scott and White Medicare	$287.06
Rate for Payer: Superior Health Plan EPO	$287.06
Rate for Payer: Superior Health Plan Medicare	$287.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$287.06
Rate for Payer: Universal American Medicare	$287.06
Rate for Payer: Wellcare Medicare	$287.06
Rate for Payer: Wellmed Medicare	$287.06

SLP Neurobehavioral Status Examination Units BCE

Facility

$527.00

Service Code	CPT 96116 GN
Hospital Charge Code	5900830
Hospital Revenue Code	918
Min. Negotiated Rate	$5.13
Max. Negotiated Rate	$650.28
Rate for Payer: Aetna Commercial	$289.85
Rate for Payer: Aetna Medicare	$430.59
Rate for Payer: Amerigroup CHIP/Medicaid	$47.43
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$287.06
Rate for Payer: Amerigroup Medicare	$287.06
Rate for Payer: BCBS of TX Blue Advantage	$158.10
Rate for Payer: BCBS of TX Blue Essentials	$189.72
Rate for Payer: BCBS of TX Medicare	$287.06
Rate for Payer: BCBS of TX PPO	$210.80
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cash Price	$463.76
Rate for Payer: Cigna Commercial	$650.28
Rate for Payer: Cigna Medicare	$287.06
Rate for Payer: Employer Direct Commercial	$287.06
Rate for Payer: Humana Medicare/TRICARE	$287.06
Rate for Payer: Molina Dual Medicare/Medicaid	$287.06
Rate for Payer: Molina Medicare	$287.06
Rate for Payer: Multiplan Auto	$342.55
Rate for Payer: Multiplan Commercial	$342.55
Rate for Payer: Multiplan Workers Comp	$342.55
Rate for Payer: Scott and White EPO/PPO	$5.13
Rate for Payer: Scott and White Medicare	$287.06
Rate for Payer: Superior Health Plan EPO	$287.06
Rate for Payer: Superior Health Plan Medicare	$287.06
Rate for Payer: Universal American Dual Medicare/Medicaid	$287.06
Rate for Payer: Universal American Medicare	$287.06
Rate for Payer: Wellcare Medicare	$287.06
Rate for Payer: Wellmed Medicare	$287.06

SLP Neurobehavioral Status Examination Units BCE

Facility

$527.00

Service Code	CPT 96116 GN
Hospital Charge Code	5900830
Hospital Revenue Code	918
Rate for Payer: Cash Price	$463.76

SLP Pharyngeal Swallow Eval Units

Facility

$448.00

Service Code	CPT 92610 GN
Hospital Charge Code	4405619
Hospital Revenue Code	444
Min. Negotiated Rate	$60.93
Max. Negotiated Rate	$291.20
Rate for Payer: Aetna Commercial	$246.40
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$129.18
Rate for Payer: BCBS of TX Blue Essentials	$154.42
Rate for Payer: BCBS of TX PPO	$172.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$291.20
Rate for Payer: Multiplan Commercial	$291.20
Rate for Payer: Multiplan Workers Comp	$291.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$60.93

SLP Pharyngeal Swallow Eval Units BCE

Facility

$448.00

Service Code	CPT 92610 GN
Hospital Charge Code	4405619
Hospital Revenue Code	444
Rate for Payer: Cash Price	$394.24

SLP Pharyngeal Swallow Eval Units BCE

Facility

$448.00

Service Code	CPT 92610 GN
Hospital Charge Code	4405619
Hospital Revenue Code	444
Min. Negotiated Rate	$60.93
Max. Negotiated Rate	$291.20
Rate for Payer: Aetna Commercial	$246.40
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$129.18
Rate for Payer: BCBS of TX Blue Essentials	$154.42
Rate for Payer: BCBS of TX PPO	$172.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cash Price	$394.24
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$291.20
Rate for Payer: Multiplan Commercial	$291.20
Rate for Payer: Multiplan Workers Comp	$291.20
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$60.93

SLP Speech AAC Eval Addl Half Hour Units

Facility

$91.00

Service Code	CPT 92608 GN
Hospital Charge Code	5902628
Hospital Revenue Code	444
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$50.05
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$92.19
Rate for Payer: BCBS of TX Blue Essentials	$110.20
Rate for Payer: BCBS of TX PPO	$122.91
Rate for Payer: Cash Price	$80.08
Rate for Payer: Cash Price	$80.08
Rate for Payer: Cash Price	$80.08
Rate for Payer: Cash Price	$80.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$59.15
Rate for Payer: Multiplan Commercial	$59.15
Rate for Payer: Multiplan Workers Comp	$59.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$12.38

SLP Speech AAC Eval Addl Half Hour Units BCE

Facility

$91.00

Service Code	CPT 92608 GN
Hospital Charge Code	5902628
Hospital Revenue Code	444
Rate for Payer: Cash Price	$80.08

SLP Speech AAC Eval Addl Half Hour Units BCE

Facility

$91.00

Service Code	CPT 92608 GN
Hospital Charge Code	5902628
Hospital Revenue Code	444
Min. Negotiated Rate	$12.38
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$50.05
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$92.19
Rate for Payer: BCBS of TX Blue Essentials	$110.20
Rate for Payer: BCBS of TX PPO	$122.91
Rate for Payer: Cash Price	$80.08
Rate for Payer: Cash Price	$80.08
Rate for Payer: Cash Price	$80.08
Rate for Payer: Cash Price	$80.08
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$59.15
Rate for Payer: Multiplan Commercial	$59.15
Rate for Payer: Multiplan Workers Comp	$59.15
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$12.38

SLP Speech AAC Eval First Hour Units

Facility

$457.00

Service Code	CPT 92607 GN
Hospital Charge Code	4410033
Hospital Revenue Code	444
Min. Negotiated Rate	$62.15
Max. Negotiated Rate	$308.51
Rate for Payer: Aetna Commercial	$251.35
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$231.39
Rate for Payer: BCBS of TX Blue Essentials	$276.60
Rate for Payer: BCBS of TX PPO	$308.51
Rate for Payer: Cash Price	$402.16
Rate for Payer: Cash Price	$402.16
Rate for Payer: Cash Price	$402.16
Rate for Payer: Cash Price	$402.16
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$297.05
Rate for Payer: Multiplan Commercial	$297.05
Rate for Payer: Multiplan Workers Comp	$297.05
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$62.15

SLP Speech AAC Eval First Hour Units BCE

Facility

$457.00

Service Code	CPT 92607 GN
Hospital Charge Code	4410033
Hospital Revenue Code	444
Rate for Payer: Cash Price	$402.16

SLP Speech AAC Eval First Hour Units BCE

Facility

$457.00

Service Code	CPT 92607 GN
Hospital Charge Code	4410033
Hospital Revenue Code	444
Min. Negotiated Rate	$62.15
Max. Negotiated Rate	$308.51
Rate for Payer: Aetna Commercial	$251.35
Rate for Payer: Amerigroup CHIP/Medicaid	$80.00
Rate for Payer: BCBS of TX Blue Advantage	$231.39
Rate for Payer: BCBS of TX Blue Essentials	$276.60
Rate for Payer: BCBS of TX PPO	$308.51
Rate for Payer: Cash Price	$402.16
Rate for Payer: Cash Price	$402.16
Rate for Payer: Cash Price	$402.16
Rate for Payer: Cash Price	$402.16
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$297.05
Rate for Payer: Multiplan Commercial	$297.05
Rate for Payer: Multiplan Workers Comp	$297.05
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$62.15

SLP Standardized Cognitive Performance Test Units

Facility

$544.00

Service Code	CPT 96125 GN
Hospital Charge Code	4450060
Hospital Revenue Code	440
Min. Negotiated Rate	$48.96
Max. Negotiated Rate	$353.60
Rate for Payer: Aetna Commercial	$299.20
Rate for Payer: Amerigroup CHIP/Medicaid	$48.96
Rate for Payer: BCBS of TX Blue Advantage	$195.65
Rate for Payer: BCBS of TX Blue Essentials	$233.88
Rate for Payer: BCBS of TX PPO	$260.86
Rate for Payer: Cash Price	$478.72
Rate for Payer: Cash Price	$478.72
Rate for Payer: Cash Price	$478.72
Rate for Payer: Cash Price	$478.72
Rate for Payer: Cigna Commercial	$200.00
Rate for Payer: Multiplan Auto	$353.60
Rate for Payer: Multiplan Commercial	$353.60
Rate for Payer: Multiplan Workers Comp	$353.60
Rate for Payer: Scott and White EPO/PPO	$180.00
Rate for Payer: Superior Health Plan EPO	$73.98

Know your out-of-pocket cost for care.

All Charges